Journal of the International Academy of Periodontology 2014 16/1:9-18

Biological Implant Complications

and Their Management
Yung-Ting Hsu, Suzanne A. Mason and Hom-Lay Wang

Department of Periodontics and Oral Medicine, School of Dentistry,

University of Michigan, Ann Arbor, MI, USA.
Abstract
Background: Background: With the increasing popularity of dental implants the presence of
implant complications is rising, and the question of how to best manage these complications
still lingers in most clinicians’ minds. This paper aims to provide clinicians with an overview of
the most commonly encountered biologic implant complications as well as to provide guide-
lines as to how to treat them.
Methods: Available English literature was reviewed, including peer-reviewed journal
publications and online resources. Several treatment modalities have been proposed to manage
these complications, including non-surgical mechanical debridement, antiseptics, local and/or
systemic antibiotics, lasers, resection with or without implantoplasty and regenerative
approaches.
Results: In this guideline, it is suggested that the treatment modalities should be chosen based on
the severity of peri-implant diseases, amount of bone loss and the morphology of peri-implant
bony defects. For peri-implant mucositis or peri-implant defects with less than 2 mm
destruction, non-surgical treatments are recommended. For peri-implant defects with more
than 2 mm destruction, surgical treatments (e.g., resection with or without implantoplasty,
guided bone regeneration) are suggested that include removal of the implant if the bone loss is
beyond repair.
Conclusion: The prevention of biological implant complications relies on careful planning, a
thorough examination to assess etiological factors and a regular maintenance recall schedule.
With early diagnosis, biological implant complications should be managed based on the
severity of peri-implant disease, the amount of bone loss and the morphology of the peri-implant
bony defects.

Key words: Dental implants, implant complications, implant failure, biological

Introduction 1997). It is also important to note that these success

Osseointegration is considered the foundation of
implant stability and is defined as the direct contact
between living bone tissue and the implant surface
(Glossary of Periodontal Terms 2001). With the
increasing popularity of dental implants, the presence
of implant complications has been on the rise.
Consequently, how to best manage these complications
remains a question in all clinician’s minds.
Prior to the discussion of implant complications, it
is essential that we review the definitions of “implant
success” and “implant failure” (Table 1). In 1986,
Albrektsson and colleagues proposed the well-known
criteria for implant success based on his treatment
results using the classic Branemark systems
(Albrektsson et al., 1986). A common cited implant
success criterion proposed by Alkbrektsson states, “no
more than 1 mm of marginal bone loss during the first
year” has been included in the updated implant success
criteria that were proposed 10 years later (Roos et al.,
Correspondence to:
Hom-Lay Wang, DDS, MSD, PhD
Professor and Director of Graduate Periodontics
Department of Periodontics and Oral Medicine
University of Michigan School of Dentistry
1011 North University Avenue
Ann Arbor, Michigan 48109-1078, USA.
TEL: (734) 763-3383; FAX: (734) 936-0374
E-mail: homlay@umich.edu
criteria are only referring to pure titanium (smooth)
surface implants and not rough surface-coated
implants.In contrast, “implant failure” has been
categorized as: ailing, failing and failed implants. A
“failed” implant is characterized as not only having
radiographic bone loss but also mobility and is
essentially considered an untreatable situation
(Torosian and Rosenberg, 1993). The “ailing” implant
presents with radiographic bone loss without clinical
signs of inflammation, whereas a non-mobile implant
with both radiographic bone loss and consistent
deterioration is defined as a “failing” implant (Sakka
et al., 2012). Fortunately, both “ailing” and “failing”
implants are considered to be treatable.
Generally, implant complications can be classified
into three groups: biological, biomechanical and
e s t h e t i c c o m p l i c a t i o n s. B i o l o g i c a l i m p l a n t
complications result from the biological process that
affects peri-implant tissue and ultimately disturbs
implant function. In other words, these complications
include implant loss and inflammation of the peri-
implant tissue (Berglundh et al., 2002). Because of loss
of osseointegration, loss of implant can be further
divided into “early” or “late” implant failure based on
t h e t i m i n g o f i m p l a n t r e m ova l o r l a ck o f
osseointegration. Histologically, an implant with loss of

© International Academy of Periodontology

10 Journal of the International Academy of Periodontology 2014 16/1
osseointegration has a predominant fibrous tissue
capsule, preventing direct contact between implant and
bone and resulting in impaired implant function. Other
biological implant complications, which occur more
commonly, are peri-implant diseases. Peri-implant
diseases are comprised of peri-implantitis and peri-
implant mucositis, which are characterized by the
presence or absence of bone loss, respectively. In the
consensus reports of the Sixth European Workshop on
Periodontology (6th EWOP), “peri-implant mucositis”
was defined as inflammatory lesions limited to the
mucosa, whereas the lesions in “peri-implantitis” sites
extend to supporting bone (Lindhe and Meyle, 2008).
Recently, the 7th EWOP has confirmed that the key
diagnostic feature of peri-implant mucositis is the
presence of bleeding on probing when using a force
<0.25 Newtons. Moreover, the essential parameter for
the diagnosis of peri-implantitis is evidence of
progressive bone loss at the site of the implant (Lang
and Berglundh, 2011). However, clinicians should
remember to distinguish inflammation-induced bone
loss from biological bone remodeling when diagnosing
peri-implantitis. Table 2 summarizes the definitions and
the clinical characteristics of both peri-implant
mucositis and peri-implantitis.
The incidence of implant loss varies from the type
of prosthesis, location, and timing of implant loss.
From a meta-analysis including studies with more than
five years follow-up, the reported rate of implant loss
prior to function was 2.16-2.53%. In the late stage, the
incidence of implant loss was 2-3% and >5% with
implant-supported fixed prosthesis and overdentures,
respectively (Berglundh et al., 2002). In addition, higher
survival rates were reported in implants placed in
partially edentulous patients compared with those in
fully edentulous ridges (Esposito et al., 1998; Goodacre
et al., 2003). A higher incidence of implant loss was
observed in the maxilla in cases of patients who were
treated with a full-arch prosthesis (Goodacre et al.,
2003). The incidence of peri-implant diseases varies
from that reported in some previous literature because
of a lack of consistent criteria/definition. The
prevalence of peri-implant mucositis ranges from
38.9% to 90.9% (Fransson et al., 2008; Rinke et al., 2011).
Similarly, bone loss has been reported in 10% - 28% of
implants during various experimental periods
(Fransson et al., 2008; Karoussis et al., 2004). An
example may explain how the definition of disease
affects the prevalence.
In 1999, Roos-Jansaker and co-workers reported
that the incidence of peri-implantitis was 16% by their
definition, i.e., more than 1.8 mm bone loss (e.g., 3
threads in the Branemark system) following the first
year of function, although their results showed >56%
of implants demonstrating bone loss ≥1 threads with
or without bleeding on probing (BOP; Roos-Jansaker
et al., 2006).
Even though there are minimal absolute
contraindications to implant placement, several factors
may contribute to implant loss and the reaction of peri-
implant tissues. The primary etiology of biological
implant complications is bacterial infection. The
microbial profile of peri-implant disease is complex. In
spite of the diversity, the most predominant species are
Gram-negative anaerobic bacteria (Mombelli and
Decaillet, 2011). Unlike the microbiota of successful
osseointegrated implants (Lee et al., 1999), periodontal
pathogens (from both the orange and red complex)
have been predominantly associated with peri-implant
diseases (Al-Radha et al., 2012; Charalampakis et al.,
2012). In a recent study by Al-Radha and coworkers, 22
patients with signs of peri-implant disease were
evaluated and there was reportedly a positive
correlation between the percentage of red complex
bacteria and the severity of disease (i.e., pocket depth
and gingival index; Al-Radha et al., 2012). In addition to
microbiota, environmental factors including plaque and
individual susceptibility (Dereka et al., 2012; Mombelli
and Decaillet, 2011), smoking (Bain and Moy, 1993; De
Boever et al., 2009; DeLuca et al., 2006; Vervaeke et al.,
2012), systemic diseases/past head and neck radiation
(Anderson et al., 2013; Marchand et al., 2012; Moy et al.,
2005; Oates et al., 2009; Yerit et al., 2006), and
periodontal stability (De Boever et al., 2009) all can
potentially influence the healing capacity of the host
and ultimately affect the incidence of implant loss.
Another factor to consider is bone density, as implants
placed in type IV bone are more prone to failure than
those placed in type I bone (Goodacre et al., 2003).
Next, implant-related factors include considerations
such as implant length and diameter (Alsaadi et al., 2008;
Baqain et al., 2012; Chung et al., 2007; Monje et al., 2012),
and even modification of implant design has been
introduced to control the effects of the microgap and
minimize the reestablishment of biological width (Oh et
al., 2002; Tatarakis et al., 2012). Moreover, peri-implant
bone loss may result from surgical trauma (Eriksson and
Albrektsson, 1984; Oh et al., 2002) and implant
malpositioning (Evans and Chen, 2008; Hermann et al.,
2000). Another important restorative/iatrogenic factor
is residual cement. Among 42 implants with signs of
peri-implant disease, Wilson found that 80.95% of the
cases were associated with residual cement. The
resolution of the clinical and endoscopic signs was
observed in most of the cases (76%) 30 days after the
cement was removed (Wilson, 2009).
To c o n t r o l i n f l a m m a t i o n a n d r e g a i n
osseointegration, several decision trees have been
proposed. In 1997, Lang and coworkers published a
decision tree, named “Cumulative Interceptive
Supportive Therapy (CIST).” In this chart, the
treatment decision is based on the pocket depth, plaque
index, morphology of defects and the presence of BOP
(Lang et al., 1997). Later, a flow chart was suggested by
Mombelli. In this flow chart, the treatment is given
according to the findings from clinical and radiographic
 Yung-Ting Hsu et al.: Management of biological implant complications 11
examination and microbial tests (Mombelli, 2002). In
2011, Okayasu and Wang recommended a decision tree
for the management of peri-implant diseases. For the
first time, the amount of bone loss was proposed to be a
critical factor in determining treatment strategies
(Okayasu and Wang, 2011). More recently, Aljateeli and
colleagues recommended another decision tree to
manage “peri-implant bone loss” (Aljateeli et al., 2012).
In this decision tree, both etiology and defect
morphology were taken into consideration. Thus, it
should be noticed that this is a guideline for the
treatment of not only biological but also biomechanical
implant complications. This purpose of this manuscript
is to provide a guideline for the management of
biological implant complications. In addition, common
biological implant complications are discussed as well as
a review of the currently available treatment strategies.
Decision tree: the management of biological
implant complications
Focusing on the management of biological implant
complications (i.e., implant loss, peri-implant mucositis
and peri-implantitis), a decision process is proposed in
Figure 1. In addition to accurate diagnosis of the
etiologic factors, the treatment modalities should be
chosen based on the severity of peri-implant diseases,
amount of bone loss and the morphology of peri-
implant bony defects.
In order to control the inflammation and stop
disease progression, numerous nonsurgical and surgical
treatments have been proposed. To gain additional
benefits, adjunctive therapy may be given such as
antiseptics, or local and/or systemic antibiotics, as well
as application of laser therapy. It should be kept in mind
that it is difficult to compare the results of many of
these studies because of the heterogeneity of
experimental designs and the diverse definitions of
peri-implant diseases that were used throughout the
literature. Thus, clinicians should remember and take
note of the clinical significance and potential
applications of these treatments when interpreting
these data.
Non-surgical approaches
To disrupt the biofilm around implants, mechanical
debridement has been applied using hand instruments,
sonic instruments, ultrasonic instruments and air-
abrasive devices. For the treatment of peri-implantitis, a
double-blinded randomized trial was conducted by
Renvert and co-workers (2009). Thirty-one patients
were enrolled in the study and infected implants were
treated using either titanium curettes or ultrasonics.
Although there was improvement in plaque and
bleeding scores, both treatment modalities failed to
reduce pocket depth or bacterial counts during the 6-
month experimental period (Persson et al., 2010;
Renvert et al., 2009). The minimal effectiveness of
mechanical debridement was also confirmed by Sahm
and colleagues (2011). Although the authors reported
improved BOP scores with the air-abrasive device, the
reductions in probing depth (PD) were less than 0.6 mm
(Sahm et al., 2011).
In contrast, positive outcomes have been
demonstrated with treatment of peri-mucositis utilizing
mechanical therapy. In both animal and human studies,
research suggests that mechanical debridement alone is
effective in controlling peri-implant mucositis in terms
of PD reduction, clinical attachment loss (CAL) gain,
plaque reduction and control of inflammation.
However, the results of these studies did not lend
support to the additional benefit of adjunctive
antiseptic therapy in conjunction with mechanical
treatment (Porras et al., 2002; Trejo et al., 2006).
As an adjunct therapy to mechanical debridement,
local and systemic antibiotics have also been evaluated.
Compared with chlorhexidine gel, significantly better
outcomes have been observed with the use of
minocycline microspheres for the treatment of peri-
implant diseases. Additionally, the authors claimed that
repeated antimicrobial therapy sustained the PD
reduction and the level of microbial pathogens up to 12
months following treatment. Nevertheless, the mean
PD reduction in the deepest pockets was 0.6 mm at 12
months in both the single and repeated antibiotic
delivery groups (Renvert et al., 2006; Renvert et al.,
2008). Significant but minimal benefits on probing
attachment loss (PAL) gains (0.6 mm) were also
observed with the use of doxycycline hyclate gel
(Buchter et al., 2004). On the other hand, limited studies
have been conducted that investigate the effects of
systemic antibiotics. In terms of reduction of bleeding
index and PD, the use of ornidazole appeared to be
effective, as was reported in a case series (n = 9) with
nine implants that had a 12-month follow-up (Mombelli
and Lang, 1992). A recent randomized clinical trial with
a larger sample size failed to show any benefit of
systemic azithromycin administration in the treatment
of peri-implant mucositis (Hallstrom et al., 2012). Based
on the scarcity of data that are currently available, more
studies are needed to provide conclusive evidence
regarding the effects of adjunctive systemic antibiotics
for the treatment of peri-implant diseases.
In recent years, the application of laser therapy has
been introduced to treat peri-implant diseases. Without
surgical approaches, some studies were conducted to
compare the effects of laser devices with mechanical
debridement. A series of studies published by Schwarz
and coworkers evaluated the non-surgical treatment
outcomes of Er:YAG laser treatment within 12 months.
In spite of significant improvement in BOP reduction
during the experimental periods, the laser application
only exhibited significant CAL gain at 3 and 6 months
post-operatively compared with baseline. However,
there were no significant differences in PD or CAL
changes between laser-treated and control (mechanical
debridement using plastic curettes in combination with
12 Journal of the International Academy of Periodontology 2014 16/1

Table 1. Definitions of implant success

Albrektsson  That an individual, unattached implant is immobile when tested clinically

et al., 1986  That a radiograph does not demonstrate any evidence of peri-implant radiolucency
 That vertical bone loss be less than 0.2 mm annually following the implant’s first year of
service
 That individual implant performance be characterized by an absence of persistent and/
or irreversible signs and symptoms such as pain, infection, neuropathies, paresthesia, or
violation of the mandibular canal
 That, in the context of the above, a successful rate of 85% at the end of a 5-year
observation period and 80% at the end of a 10-yr period be a minimum criterion for
success.
Smith et al.,  The individual unattached implant is immobile when tested clinically
1989  No evidence of peri-implant radiolucency is present as assessed on an undistorted
radiograph
 The mean vertical bone loss is less than 0.2 mm annually after the first year of service
 No persistent pain, discomfort, or infection is attributable to the implant
 The implant design does not preclude placement of a crown or prosthesis with an
appearance that is satisfactory to the patient and dentist
 By these criteria, a success rate of 85% at the end of a 5-year observation period and
80% at the end of a 10-year period are minimum levels for success.
 Absence of mobility is checked by individual stability testing of the
Roos et al., Grade 1 unattached implant, using a light tightening force of an abutment
1997 screwdriver without simultaneous counteracting of the force via an
abutment clamp. Any mobility or sensation/pain from the anchorage
unit is regarded as a sign of lost osseointegration.
 Radiographic evaluation of each implant reveals not more than 1.0 mm
of marginal bone loss during the first year of loading, followed by not
more than 0.2 mm resorption per year, as well as absence of peri-
implant pathosis, such as a peri-implant radiolucency.
 Severe soft tissue infections, persistent pain, paresthesia, discomfort,
etc., are absent.
Grade 2  Radiographic evaluation of each implant reveals not more than 1.0 mm
of marginal bone resorption during the first year of loading, followed
by not more than 0.2 mm of resorption per year, as well as absence of
peri-implant pathosis, such as peri-implant radiolucency.
 Severe soft tissue infections, persistent pain, paresthesia, discomfort,
etc., are absent.
 Radiographic evaluation of each implant reveals not more than 0.2 mm
Grade 3 of marginal bone resorption during the first year, but previously more
than 1.0 mm of bone loss has taken place. Peri-implant pathosis, such
as peri-implant radiolucency, is absent.
 Severe soft tissue infections, persistent pain, paresthesia, discomfort,
etc, are absent.
Success  No pain or tenderness upon function
ICOI (optimal  No mobility
implant health)  <2 mm radiographic bone loss from initial surgery
health scale  No exudate history
(Misch et al.,  No pain on function
2008) Satisfactory  No mobility
survival  2-4 mm radiographic bone loss
 No exudate history
Compromised  May have sensitivity on function
survival  No mobility
 Radiographic bone loss >4 mm (less than 1/2 of implant body)
 Probing depth >7 mm
 May have exudates history
Failure  Pain on function
(clinical or  Mobility
absolute  Radiographic bone loss >1/2 length of implant
failure): any of  Uncontrolled exudate
following  No longer in mouth
 Yung-Ting Hsu et al.: Management of biological implant complications 13
Table 2. The definitions and the clinical characteristics of both peri-implant mucositis and peri-implantitis
Peri -implant mucositis
Definition An inflammatory lesion that resides
in the mucosa
Characteristics Bleeding on probing
(<25 Newtons force; key feature)
Redness
Swelling
0.2% chlorhexidine (CHX) irrigation) groups at any
timepoint (Schwarz et al., 2006a; Schwarz et al., 2005).
The result was further confirmed by later studies
comparing the use of the Er:YAG laser with an air-
abrasive device (Persson et al., 2011; Renvert et al., 2011).
In regards to microbiological changes, a single episode
of laser application may reduce the counts of
Fusobacterium nucleatum naviforme and Fusobacterium
nucleatum nucleatum within one month after therapy.
Nevertheless, the antimicrobial effects failed to be
maintained at the 6-month follow-up time point
(Persson et al., 2011).
Surgical approaches
In the treatment of peri-implantitis, surgical approaches
appear to be a predictable method over a short-term
period (Renvert et al., 2012). In general, surgical therapy
consists of access flap surgery, degranulation and
decontamination of the implant surface. To gain access
and facilitate home care, resective surgery is performed
either alone or in conjunction with implant surface
modification (implantoplasty). In contrast, regenerative
procedures should be considered to regenerate bone
(Renvert et al., 2012).
Resective surger y consists of an apically
repositioned flap (APF) along with bone re-contouring,
which ultimately leads to pocket reduction. With a 2-
year follow-up, Serino and Turri (2011) reported
positive outcomes of resective treatment on 86
implants with peri-implantitis. In addition, more
implants (74%) with a minimal amount of initial bone
loss (2-4 mm) returned to healthy status (no signs of
peri-implant diseases) compared to those implants with
>5 mm initial bone loss (40%; Serino and Turri, 2011).
Without implantoplasty, a recent double-blind
randomized controlled trial evaluated the effects of
resective surgery with surface debridement on a total of
79 implants from 30 patients. Significant clinical
improvements in terms of PD and BOP reduction were
observed over a 12-month follow-up time period (de
Waal et al., 2013). On the contrary, some authors
proposed that implantoplasty may augment the benefits
Peri -implantitis
An infectious disease that also affects the
supporting bone
Changes in the level of the crestal bone
Bleeding on probing
Possible concomitant deepening of peri-
implant pockets
The presence of pus
of resective therapy for peri-implantitis. In the
comparative studies published by Romeo and co-
researchers (2005, 2007), implantoplasty groups
exhibited higher implant survival rates and less alveolar
bone loss over the 3-year experimental periods. Better
clinical results (lower PD, PAL and modified bleeding
index) were also observed at the sites with surface
modification (Romeo et al., 2005; Romeo et al., 2007). As
for concerns of thermal changes during implantoplasty,
an in vivo study indicated that minimal temperatures
(approximately 1.5ºC) were generated during
implantoplasty with a properly selected bur and cooling
system (Sharon et al., 2011).
In addition to resective procedures, regenerative
therapy is another treatment modality to re-establish
osseointegration around a dental implant. Before any
regenerative procedures can work, a surface
detoxification must be done first. Decontamination of
the implant surface can be performed by way of several
methods. Similar to non-surgical mechanical
debridement, the main g oal of mechanical
decontamination is to rupture the implant biofilm.
In addition, chemical modalities have been
introduced to suppress bacterial load in peri-implantitis
sites. They include hydrogen peroxide (Roos-Jansaker et
al., 2011; Roos-Jansaker et al., 2007b), saline (Behneke et
al., 2000; Schwarz et al., 2008), 35% phosphoric acid gel,
CHX (Hammerle et al., 1995; Khoury and Buchmann,
2001; Wiltfang et al., 2012), citric acid (Khoury and
Buchmann, 2001), and EDTA (Roccuzzo et al., 2011).
Another choice for implant surface decontamination is
laser application, such as the CO2 laser (Deppe et al.,
2007; Romanos and Nentwig, 2008), the diode laser
(Bach et al., 2000) and the Er:YAG laser (Schwarz et al.,
2011b). Despite decontamination modalities that have
been widely applied in combination with surgical
treatments, some authors questioned the effects of
these procedures. In a recent meta-analysis, Renvert and
c owo r ke r s r e f u t e d t h e b e n e f i t s f r o m l a s e r
decontamination (Renvert et al., 2012). Compared with
those who received conventional mechanical
debridement (plastic curettes), the laser-treated group
14 Journal of the International Academy of Periodontology 2014 16/1
Figure 1. The management of biological implant complications
did not exhibit better inflammation control (i.e., higher
BOP reduction and CAL gain) in the treatment of
advanced peri-implantitis (Schwarz et al., 2011a). With
resective surgery, the CHX/cetylpyridinium chloride
(CPC) group achieved greater reduction of bacterial
load, but failed to show any clinical superiority when
compared to the control group (without CHX/CPC; de
Waal et al., 2013). However, it is difficult to compare the
effects of different treatment modalities because more
than one decontamination method has been used in
most studies. Furthermore, systemic antibiotics were
given in most of the studies. To reach optimum re-
osseointegration, decontamination of implant surfaces
via chemical or mechanical techniques are still the most
highly recommended (Subramani and Wismeijer, 2012).
To date, there is no consensus on the indications and/or
criteria for when to perform peri-implant regeneration.
From the criteria of case selection in previous studies,
the defect types that have been suggested include crater-
like or saucer-shaped defects (Behneke et al., 2000;
Roccuzzo et al., 2011; Wiltfang et al., 2012), intrabony
defects with 3 mm depth (Schwarz et al., 2006b;
Schwarz et al., 2008) and >3 threads of progressive loss
(Roos-Jansaker et al., 2011; Schwarz et al., 2011b). As is
 Yung-Ting Hsu et al.: Management of biological implant complications 15
seen with the natural dentition, generally, the treatment
of deeper defects is more predictable for regenerative
purposes (Renvert et al., 2012). Numerous grafting or
barrier materials have been used either alone or together
for purposes of peri-implant regeneration, such as
autogenous bone grafts, bone blocks (Behneke et al.,
2000; Wiltfang et al., 2012), xenografts (Schwarz et al.,
2009; Wiltfang et al., 2012), alloplasts (Schwarz et al.,
2009), expanded polytetrafluoroethylene (e-PTFE)
membranes (Jovanovic et al., 1992; Khoury and
Buchmann, 2001) and collagen membranes (Khoury
and Buchmann, 2001; Schwarz et al., 2009). Overall,
promising outcomes have been reported with
regeneration using bone grafts alone (Behneke et al.,
2000; Wiltfang et al., 2012) or in combination with the
barrier membranes (Roos-Jansaker et al., 2011; Schwarz
et al., 2008). In contrast, some authors have claimed that
the application of membranes may not resolve peri-
implantitis (Jovanovic et al., 1992; Roos-Jansaker et al.,
2007a; Roos-Jansaker et al., 2007b). These results may
derive from non-submerged techniques and the
following membrane early exposure. However, Roos-
Jansaker et al., demonstrated in a case series that the
submerged technique resulted in better treatment
outcomes (Roos-Jansaker et al., 2007a). Furthermore,
Khoury and Buchmann reported a high incidence
(58.6%) of post-operative complications in the
membrane-treated sites (Khoury and Buchmann,
2001). In addition, a recent case series reported
successful treatment with concomitant bone gain using
a combination of enamel matrix derivatives (EMD),
platelet-derived g rowth factors(PDGF),
xenografts/allografts and collagen
membranes/connective tissue grafts (Froum et al.,
2012).
To sum up, treatment modalities of implant
biological complications should be determined with
regard to three factors: the severity of disease, amount
of bone loss, and the morphology of peri-implant bony
defects. For implants with a large amount of bone loss
or loss of osseointegration, implant removal is highly
recommended because of the unfavorable treatment
prognosis. Guided bone regeneration is indicated in
peri-implant defects when there is bone loss affecting
less than half of the implant fixture. Although there is
no consensus among previous studies, peri-implant
defects, including circumferential defects within bony
housing and 2/3-wall intrabony defects, appear to have
more regenerative potential. On the contrary, resective
therapy (i.e., an apical positioned flap) should be
considered in defects with moderate bone loss that do
not have a favorable regenerative potential.
Additionally, to reduce plaque accumulation and
facilitate patient home care, treatment with
implantoplasty is suggested at the time of resective
surgery. Mild peri-implant disease cases can be
maintained by non-surgical treatment modalities.
Conclusion
With the increasing popularity of implant therapy,
biological implant complications are important issues
that cannot be ignored. In addition to comprehensive
examination and a thorough treatment plan, proper
surgical technique and regular maintenance play roles in
the prevention of implant complications. Clinicians
should be fully aware of the signs and symptoms of
these complications and treat them as early as possible.
Although more and more studies have been conducted
in the treatment of peri-implant diseases, the effects of
these treatment modalities should be evaluated in the
future literature.
Acknowledgments
The authors are grateful for the support from the
Periodontal Graduate Student Research Fund,
University of Michigan, Ann Arbor, Michigan. In
addition, the authors hereby announce that none of the
presented material poses a conflict of interest.
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